A blanket of SNOMED

By Alan Joch

Nov 14, 2005

Lingua Franca. Rosetta Stone. Holy Grail. Major headache. The gathering momentum for electronic health records (EHRs) in public hospitals is revealing the nagging realization that EHRs are only marginally useful if they can't communicate with records created by other departments or health care organizations.

One of the biggest stumbling blocks to the widespread use of health records is medical terminology. Individual organizations and clinicians use a variety of names to identify the same diseases. But if an EHR system could understand that "pneumonia" and "pneumanitis" referred to the same ailment, physicians and patients would see big benefits in better outcomes and disease prevention.

For years, an international standard known as Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) has yet to fulfill its promise to be the gold standard in medical terminology in the United States. For a number of reasons, that may be about to change.

"SNOMED really is the only viable candidate for a health care core terminology," said Gail Graham, director of health data and informatics at the Veterans Health Administration in Washington, D.C. VHA is working to incorporate SNOMED CT-based clinical problem lists into its EHR application.

As SNOMED CT interest grows, public-sector chief information officers will have to put it on their strategic radar screens. However, roadblocks to adoption remain, which may make terminology standards an information technology challenge for years to come.

Gathering steam

Support for SNOMED CT is growing as the standard matures. Developed 40 years ago and maintained by SNOMED International, a division of the College of American Pathologists, the standard currently defines more than 366,000 medical concepts, such as pneumonia and its synonyms. In 2003, the National Institutes of Health's National Library of Medicine reached a licensing agreement with SNOMED International that provides for free downloads of SNOMED CT through 2008.

Vendors are taking notice, too. Health care software giant Cerner reportedly is aggressively recruiting SNOMED CT experts to help incorporate the standard into its products. Epic Systems is working on similar efforts. Greenway Medical Technologies, an EHR vendor that caters to small clinics and individual physician practices, plans to use SNOMED CT terminology in some laboratory modules by next spring.

But although cost and vendor support may no longer be inhibiting factors, other challenges still thwart SNOMED CT's adoption. Even the VHA, which is further along than most organizations, doesn't expect a broad implementation until fiscal 2007.

First, confusion remains between SNOMED CT and other standards, such as ICD-9-CM disease classification codes. Because SNOMED CT is more comprehensive and enables clinicians to define illnesses with greater specificity, health care analysts expect it will better enable records sharing and analysis among hospitals, while ICD-9-CM remains primarily a code source for billing.

SNOMED CT adoption is also a battleground in a culture war that's pushing for changes in clinician work patterns.

"The very fact that [SNOMED CT requires] a physician to go to a computer screen and maybe learn a few keystrokes in a screen can be a barrier," said Dr. Franklin Elevitch, chairman of SNOMED International Authority and CEO of Health Care Engineering, a Palo Alto, Calif.-based consulting firm. "There's a lot of human engineering that has to be done. Physicians are saying, 'I don't want to be regimented,' or 'If I hit the wrong key, it will blow everything up.'"

Behind-the-scenes is best

The VHA is eyeing SNOMED CT for EHRs to create sophisticated decision-support modules to aid diagnoses and disease trend analyses. By aggregating data from various EHRs, health officials hope to use sophisticated data analysis to spot disease trends and identify treatment best practices.

But first the VHA is working to make SNOMED CT transparent to doctors and nurses as they interact with EHRs. "We've already jumped over the hurdle of [EHR] adoption," Graham said. "So if we do [SNOMED CT] right, it shouldn't be glaringly evident in the entry and recording of clinical information. It should be something that happens in the background."

Clinicians shouldn't see a SNOMED CT code on their documentation, "they should see the verbiage that's applicable to their setting," she added.

One way to do this is to tailor EHR interfaces so that doctors and nurses "don't have to pick from hundreds of thousands of terms," Graham added. "We're looking at things like nursing admission templates. So when a patient gives a response, the nurse can record it in discrete, SNOMED-readable ways that can be used in the computer systems."

Real-world results

To help it with its SNOMED CT transition, the VHA is looking to clinical delivery giant Kaiser Permanente as a model. The health care network has participated
in SNOMED CT development and implementation for the past decade, driven by data analysis and cost savings incentives.

"Because of our size, we deal with a gazillion vendors, and [traditionally] each one has had its own terminology," said Robert Dolin, a doctor at Kaiser Permanente's La Palma, Calif., facility and physician lead for the organization's Convergent Medical Terminology Project, which oversees terminology deployment in national EHR systems. Dolin also serves on the editorial board of SNOMED International.

"When vendors start adopting the standard, we see the cost of building [data] interfaces start to go down," he said. "So, on one hand, you're seeing return on your [SNOMED CT] investment because we're doing more specific decision support that clinicians find useful. Meanwhile, our costs of building interfaces are going down."

Still, SNOMED CT skeptics remain within Kaiser Permanente. To sway them, Dolin created what he calls the Enterprise Query Model, which simplifies searches about disease trends in patient records. Thus, clinicians ask for all the codes for E. coli and the query engine returns all of the relevant SNOMED CT codes.

"Now I can go into my patient database and I can simply say, 'Show me all of the patients who have had any one of these codes,'" Dolin said. "My ability to avoid missing any patients and to return just the relevant records, along with the sensitivity and the specificity of querying against patient data, goes way up."

Nix data mapping

Given SNOMED CT's relatively small presence in hospitals, how should CIOs prepare for a world based on the standard? Focus on cultural not technical problems, said John Quinn, chief technology officer for health care products at management consultant Accenture.

"The challenge for any CIO is to get the physicians to use it," Quinn said. "You cannot spend millions of dollars on one of these systems and years of putting it in and then have physicians say, 'It wastes my time, it takes too long, it introduces too many errors.' Whether those are true or just widely accepted rumors, it doesn't make any difference. You failed."

Success comes through working with end users, hospital administrators and steering committees to build consensus for EHRs and standardized terminology, and to ease everyone into new ways of doing their work, he said.

Finally, CIOs should avoid tedious data-integration schemes, Dolin said. "The biggest cost in implementing SNOMED is mapping all of the legacy data" into SNOMED CT, he said. Instead, CIOs should scout out software vendors that are working to integrate the standard into their EHR systems. "Ask them if you can just use SNOMED in the particular application or if the vendor has its own native terminology that you then have to create this complex mapping for," he said.

The standard might not be the Holy Grail, but it could bring relief for one more IT headache.